Verification of Service Hours
Complete this form and include with your submitted materials to complete each level of the
Designation Program
Student Name: ________________________________________________
UAkron Email: _________________________________________________
Level ________________________
(identify which level of program you are completing: I, II, or Advanced)
Please write a paragraph describing what you learned by doing this service:
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TO BE COMPLETED BY AGENGY/AGENCIES WHERE SERVICE WAS PEFORMED
Name of Non-Profit Agency where service was performed:
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Name of Agency Volunteer Supervisor: __________________________________________
Signature, date and telephone number of Agency Volunteer Supervisor:
___________________________________________________________________________
Total number of service hours completed: _____________________
I affirm that the information on this form is correct:
Student Signature: _____________________________ Date: __________________________